covid-19 tracheostomy guidance - cardiff icu

Tracheostomy & Covid-19 Version 5.0

14th April 2020 PT of 13

Considerations for Tracheostomy in the Covid-19 Outbreak

Cardiff and Vale UHB

Produced by the Cardiff and Vale UHB Tracheostomy Steering Group

Introduction:

Within Cardiff and Vale UHB approximately 140-150 patients requring a tracheostomy each year.

These are inserted for a variety of reasons including as part of weaning from mechanical ventilation, as

an emergency airway or as part of an OMFS / ENT procedure. Over the past 3-years the care of these

patients has vastly improved and their hospital pathway become more recongised and robust.

However, the current Covid-19 outbreak is likely to challenge these systems, with potentially much

increased numbers of patients requiring a tracheostomy (primarily to faciliate weaning from

mechanical ventialtion) and due to high demand on bed pressures, patients are likely to be discharged

to areas not familiar with caring for patients with tracheostomies.

Furthermore, it is likely that there will be an increase in patients with pre-existing tracheostomies or

laryngectomies being admitted from the community with Covid-19. These patients are likely to be

cohorted to Covid-19 wards who may have little or no experience in caring for those with

tracheostomies.

The purpose of this document is to outline the suggested care for these patients including their in-

hospital pathways. The suggestions made are based on recommendations from ENT-UK and the

National Tracheostomy Safety Programme, and reflect Cardiff and Vale UHB infection policies.

Based on current UK guidance, full PPE (long sleeve gown, FFP3 mask, gloves and visor) must be worn

for all aerosol generating procedures no matter the patients covid status.

This guide considers balancing the risks of infection control re aerosol spread of the virus versus the

best management for the patient with a tracheostomy. This guidance is written for Cardiff and Vale

UHB but may be applicable elsewhere. Other NHS Wales health boards may adapt/adopt these

guidelines without permission. The guidance may change in line with changes to NTSP or other

professional guidance and as data on tracheostomy in the Covid-19 becomes available.



Decision for Tracheostomy:

Current international evidence for Covid positive patients admitted to critical care suggests high

mortality (up to 60%). In those that survive, tracheostomy has been suggested to aid facilitate weaning

from mechanical ventilation, reduce risks assocaited with failed extubation and faciliate flow from

critical care.

The decision to proceed to insert a tracheostomy must be made by an Consultant in Intensive Care

Medicine. This decision may be supported by input from ENT, Oro-maxillofacial surgery, Cardiff

Tracheostomy Team and wider MDT. The likely patient trajectory must be considered including

discharge destination and access to approraite therapies. NTSP and ENT-UK recommendations suggest

a tracheostomy should not be inserted until 14 days after critical care admission when the risk of the

patient remaining infectious is vastly reduced. Additionally, patients should be on no more than 40%

oxygen.

Criteria for Tracheostomy Insertion:

The following are indicators for readiness for tracheostomy. Note this is not an exhaustive list and

cases will be considered on a patient by patient basis:

≥ 14 days post critical care admission

Apyrexial ≥ 48 hours

PEEP ≤ 10cm H2O

FiO2 ≤ 0.4

NG feed stopped 6 hours prior to surgery (e.g. 2am)

Insertion Method:

Within the literature there is debate regarding whether percutaneous insertion results in less aerosol

generation that a surgical approach. Due to the extreme demands being placed likely to be placed on

critical care and the intensive care medicine consultants, it is likely that a higher than normal

proportion of tracheostomies will be completed surgically.

Surgical:

Booking Process:

Once the decision has been made for a surgical tracheostomy, the patient must be listed via

TheatreMan by 10am on the day prior to the completion of the trachoestomy. They must also be listed

on the whiteboard in the specialist services hub (critical care resource room). The CEPOD list will be

used as an interim booking process for tracheostomies (patients to be highlighted as ‘covid



tracheostomy’), however theatre slots on Monday, Wednesday amd Friday will be ringfenced for

tracheostomy insertion. Surgical tracheostomies will be avialable on other days but theatre availability

will not be ringfenced and therefore may be impacted by other emergencies requiring CEPOD theatres.

All booked surgical tracheostomies will then be discussed between intensivist, anaesthetist (see

appendix 1 for anaesthetic care bundle) and surgeon at 1pm on that day (the day prior to surgery) in

the A3/B3 corridor. A tracheostomy booking form needs to be completed by the critical care team,

outside of the ‘hot zone’, and brought to the Cepod booking hub. This contains essential eligibility

criteria relating to the patient’s condition.

The critical care consultant will be responsible for the consenting process and the patient does not

need to be reviewed by the operating consultant prior to the procedure.

Location and Staffing:

All surgical tracheostomies will be perfomed in a designated Covid theatre and will be completed in

pre-allocated sessions (see surgical tracheostomy SOP appendix 2). The procedure must be completed

by an experienced consultant surgeon (ENT or OMFS) in the presence of an experienced anaesthetic

consultant. This will reduce the duration of the procedure and lesson the duration of aerosol

generation. All surgical tracheostomies should be completed in theatres with the most frequent air

changed (theatres 12-15 with negative pressur corridor) and with as minimal staff present as safely

allows. PPE must be worn as per UHB recommendations for aerosol generating procedures.

Process for Patient Collection:

The nurse caring for the patient on the night prior to the tracheostomy will be informed of the

requirement for the patient to be NBM 6 hours prior to the procedure. The daytime nurse will then be

responsible for preparing the patient for transfer to theatre as guided by the intensive care team. Prior

to theatre a theatre care plan will be started, consent form signed by ICM consultant, and a covid

specific surgical tracheostomy checklist completed (see appendix 3). This will include collecting a

tracheostomy tube from the stock on B3 to theatre with the patient.

Tracheotwist plus tracheostomy tubes will be used as standard with size 8 tubes primarily being used.

This will be guided by the critical care medical staff and physiotherapy. If an alternative tube is

required then this will be collected by theatre ‘runners’ during the procedure and collected from the

main store on B3 corridor. Patients will be collected and returned from theatre as per existing

arrangements.

Patients must be tranfered to thatre using critical care’s oxylog and transport monitor. As per critical

care recommendations, appropriate viral filters (or viral HME) must be in place, and the closed suction

device, adaptor and catheter mount must remain in place.



Intra-Operative Recommendations:

A WHO checklist will be completed prior to intiating the procedure. This will include a team brief and

role allocation.

Intra-operatively, ENT-UK recommend advancing the ETT to near the level of the carina to reduce the

risk of accidental cuff damage when creating a tracheal window, and to ensure that any ongoing

ventilation is distal to and isolated from the surgical site. Critical care (via the MERIT team) will be

using cut ETT’s to reduce deadspace and dislodgement during proning. Therefore, there may be a

requirement to change the existing ETT an uncut ETT. This tube can then be advanced to the necessary

level ensuring adequate ventilation remains – to date this has not been required however it may be

required in some cases. Neuromuscular blockade should be maintained, to reduce the potential for the

patient to cough during the procedure. Due to incidences of sputum plugging, suction should be

performed prior to starting the procedure. It may also be beneficial to perform a bronchoscopy

(caution to be taken as AGP). The bronchoscopy, if required, can be completed via the existing closed

suction adaptor (suction catheter removed).

The anaesthetic consultant must be informed prior to the trachea being opened. After this point the

following should occur: 1) mechanical ventilation should cease and the APL valve opened to allow

passive expiration; 2) the trachea should be opened (if cuffed not damaged then ventilation may be

provided to pre-oxygenate prior to continuing); 3) ETT cuff deflated and ETT drawn back to above level

of stoma; 4) suction provided via the newly created stoma, 5) cuffed tracheostomy tube inserted and

cuff hyperinflated; 5) ventilatory circuit attached to the tracheostomy tube including the closed suction

device, adaptor and catheter mount; 6) ventilation re-started via the tracheostomy tube (confirm

ventilation); and 7) careful removal of ETT. This process will reduce potential for contamination and

reduce risk to health care staff. Once adequate ventilation has been achieved, a bronchoscope must be

passed via the tracheostomy tube to confirm position and patency of the bronchial tree.

Post procedure the patient should be transferred back to critical care with extreme caution taken not

to cause disconnection of the ventilator circuit. Additional guidance for surgical tracheostomies has

been produced by ENT-UK and other than differences stated above, the existing Cardiff and Vale UHB

SOP for surgical tracheostomy remains active.

Percutaneous:

Booking:



Percutanous tracheostomies will all be completed in theatre and therefore will need to be booked via

TheatreMan by 10am on the day prior to the planned procedure. Initially this process will use the

CEPOD list with ‘Percutaneous COVID tracheostomy’ listed on the booking. At the 1pm meeting it will

be highlighted that the procedure will be percutaneous and ENT consultant must be aware of

completion in case of complications.

Location and Staffing:

As previously stated, all percutaneous tracheostomies will be performed in a designated COVID

theatre. This is to reduce the impact on critical care resources / staffing, and reduce risks associated

with staff exposure in surrounding areas.

Percutenous tracheostomies must be performed by consultants in ICM with significant experience in

percuatenous tracheostomy tube insertion, and an additional experienced consultant responsible for

managing the upper airway. This will reduce the likelihood of intra-procedure complications and

reduce the procedure time. These consultants may require allocated days within their rota to ensure

availability to complete tracheostomies across the critical care cohorts.

All staff must wear appropriate PPE and a clear plan of the procedure be discussed prior to initiaion.

This plan must include actions in the event of adverse or unexpected events e.g. inability to insert

tracheostomy tube. A Loccsip must be followed and completed at all times.

Process for Patient Collection:

The nurse caring for the patient on the night prior to the tracheostomy will be informed of the

requirement for the patient to be NBM 6 hours prior to the procedure. The daytime nurse will then be

responsible for preparing the patient for transfer to theatre as guided by the intensive care team. A

percutaneous tracheostomy insertion kit will go to theatre will the patient. The consultant intensivist

completing the procedure will select the size of traceotwist plus tracheostomy tube to be used. This

will then go to theatre will the patient. Theatre will contact critical care once they are ready for the

patient to be taken across ready for the procedure.

Intra-Procedure Recommendations:

A WHO checklist will be completed prior to intiating the procedure. This will include a team brief and

role allocation.

To prevent potential damage to the ETT or ETT cuff, the ETT must be withdrawn to a level just below

the vocal cords prior to starting the percutaneous technique. This should be completed using a CMAC

laryngoscope (used to reduce potential risk to healthcare staff). The ETT management needs to be

discussed in detail at the team brief. Due to incidences of sputum plugging, suction should be



performed prior to starting the procedure. It may also be beneficial to perform a bronchoscopy

(caution to be taken as AGP).

As per surgical insertion, the consultant responsible for the upper airway must be informed prior to

insertion of the dilator. At this point ventilation may be ceased until insertion of the tracheostomy, cuff

inflation and connection of the ventilator circuit to the tracheostomy. The position of the

tracheostomy tube should be confirmed by presents of ETCO2, ventilator waveforms and chest wall

movement. The use of stethoscopes to confirm air movement is not recommended due to potential to

breach PPE. The pre-existing percuataneous tracheostomy LoccSIP must be completed prior to the

patient returning to critical care. Bronchoscopy may be beneficial to confirm tracheostomy tube

location.

Tracheostomy Care:

Critical Care:

For patients on mechanical ventilation the folllowing should apply:

PPE to be worn throughout as per local guidance

Closed suction should be mandatory, with subglottic suction completed at least 4-hourly

The frequency of inner tube inspection / changes should be reduced to 6-hourly unless evidence of inner tube becoming blocked within this time. Prior to changing the inner tube either the ‘O2 suction’ or ‘manual disconnect’ option must be used to reduce aerosol spread on disconnection. Caution must be taken when cleaning the inner tube – staff should have a lower threshold to use a new inner tube where the existing one is more difficult to clean.

Tapes and dressings should continue to be changed once a day – at least one member of staff with experience of managing patients with tracheostomies must be present and lead the change

The use of ‘leak speech’ or passy-muir valves is discouraged and must be discussed with a consultant in ICM prior to use, and where deemed appropriate, must be first trialled by either speech and language therapy or a senior physiotherapist (static critical care physiotherapy staff only).

Any patients admitted to critical care from the community with pre-existing cuffless tubes must be changed to cuffed tubes prior to initiating mechanical ventilation.

For patients not requiring mechanical ventilation:

Where possible, heat moisture exchangers (‘Swedish nose’ not buchanan protector) to be used – this may be used in conjunction with closed suction - Low flow additional oxygen may be added via the HME



For those requiring higher levels of oxygen or with viscous secretions, humidified oxygen should be used as per standard

Suction to be competed only when necessary, and in accordance with local PPE policy. Subglottic suction completed at least 4-hourly

Assessment of the inner tube to be completed 4-hourly unless otherwise stated after individualised risk assessment

Tapes and dressings to be changed once a day as per standard

Decision to initiate cuff deflation to be made by consultant in ICM in conjunction with tracheostomy MDT, including Physiotherapy and Speech and Language Therapy.

Ward Based Care:

Following discharge from critical care, patients with tracheostomies must be discharged to a covid

cohort ward with appropraite PPE available for completing aerosol generating procedures. Initially, for

medicine, this will be ward C7 but as patient numbers increase, another ward will need to be allocated

to receive these patients (suggest ward C6). Due to the requirement for full PPE (water repellant long

sleeve gown, gloves, FFP3 mask and visor) for trachestomy care (as recongised AGP) it is advised to

cohort patietns together in patient bays where possible. There may be a requirement to consider

nursing allocation to ensure presence of staff with experience in tracheostomy care. Patients admitted

under different specialities e.g. neurosugery, should where possible be tranferred to that speciality. If

this area is not cohorted Covid the the patient should be cared for in a side room.

Note: All non-covid will be cared for on ward A5 (this will include those with long term tracheostomies

admitted from community locations who are not suspected to have covid) however, all tracheostomy

care (suction, inner tube, subglottic suction) must be considered an aerosol generating procedure and

therefore appropriate PPE worn!

Care considerations:

All aspects of tracheostomy care must be considered to be an aerosol generating procedure and

therefore approprate PPE must be worn (gown, gloves, FFP3 mask, visor).

Attempts should be made to cluster care to reduce exposure and requirement for donning /

doffing PPE

Where possible, heat moisture exchangers (‘Swedish nose’ not buchanan protector) to be used – this may be used in conjunction with closed suction - Low flow additional oxygen may be added via the HME



For those requiring higher levels of oxygen or with viscous secretions, humidified oxygen

should be used as per standard Assessment of inner tube, assessment of suction requirements

and subglottic suction to be completed every 2-4 hours as individually risk assessed

Tapes and dressings and assessment of cuff pressure to be completed as per standard – at

least one member of staff to be experienced / attending training on tracheostomy care

Weaning and Decannulation:

Tracheostomy weaning will only commence once the patient no longer requires mechanical

ventilation. As per standard patients will undergo cuff deflation, followed by a period of assessment to

determine appropriateness for decannulation. Where patients require elective tracheostomy tube

changes (either for downsize or for > 29 days in situ) will be delayed where possible until the patient is

Covid-19 negative. If changes are required whilst still Covid-19 positive then these will be competed by

staff highly experienced in tracheosotmy tube changes (e.g. ENT consultants or clinical specialist

physiotherapist) and appropriate PPE must be worn throughout.

Weaning and decisions regarding appropriateness for decannulation must be completed by the multi-

professional team with consideration of the patients Covid-19 status.

Emergency Management:

Emergency care should continue as per the NTSP algorithm.

Airway interventions should be planned where possible to allow appropriate PPE to be applied.

It is likely that a member of staff in a cohort area will be wearing at least some appropriate PPE

at the time of an airway emergency – call for help.

PPE should be immediately available in areas with patients that have tracheostomies including

non-covid cohort wards

Staff should ensure that they protect themselves in order to best care for our patients.

Swallow and Communication:

Factors to consider include:

Due to prolonged periods of cuff inflation, there will be a signficant impact on a patient’s

ability to communicate due to lack of airflow to the lack and therefore lack of voice. Staff will



need to consider alternative communication strategies at this time such as pen/paper,

communication charts etc. It may be appropriate to refer to Speech and Language Therapy for

further support.

Prevalance of laryngeal injury due to intubation duration for patient’s with Covid-19 and

expected delays to tracheostomy placement which can impact on voice, swallow fuction,

airway integrity and tracheostomy weaning.

Swallow assessment by a Speech and Language Therapist will be required as prolonged

intubation and prolonged duration of cuff inflation with tracheostomy in situ is more likely to

result in Dysphagia (swallowing problems)

An MDT decision to be made on individual patient basis regarding timings of proceeding with

Above Cuff Vocalisation (ACV) and cuff deflation/speaking valve use to minimise the risk of

aerosolisation.

The recent guidance from the British Laryngological Association (BLA) has stated that “all

therapist-led endoscopy should cease”, therefore the use of Fibreoptic Endoscopic Evaluation

of Swallowing (FEES) is not indicated at this time. However the role of the SLT in the care of

patients with and recovered from Covid-19 is still evolving and this guidance will be updated to

reflect changing caseloads, clinical priorities, roles and ways of working.

Tracheostomy Ward Round:

Tracheostomy ward rounds will continue to be completed at least once weekly (regularity under

review). For patients with confirmed or supsected Covid-19 within critical care, a virtual tracheostomy

ward round will be completed. This will be to reduce healthcare professionals exposure and to prevent

unnecessary use of PPE. The physiotherapist from the tracheostomy team will be reviewing these

patients regularly as part of standard physiotherapy services and therefore will be able to advise the

rest of the team of current progress. The plan from the tracheostomy ward round will then be

documented by any member of the team when next working in critical care (likely next day).

For patients with confirmed or suspected Covid-19 within cohort wards (Covid-19 cohort wards) or

isolation rooms on non-cohort wards, tracheostomy ward rounds will continue as normal with

members of the tracheostomy team wearing appropriate PPE depending on intervention.

Training and Resources:

Support for staff caring for patients with tracheostomies will be provided by the tracheostomy team –

primarily by the clinical nurse specialist. Formal has been cancelled for the forseable future, however

informal training will be available as required.



As per standard, emergency equipment (tracheostomy blue box), bed head signs and emergency

algorithms must be located in the bed area of any patient with a tracheostomy.

Additionally, online training on tracheostomy care and emergency management will be available to all

NHS Wales healthcare professionals. Tracheostomy care posters will be located on all of the wards

likely to receive patients with tracheostomies. Smaller versions of the poster will also be placed in the

bed areas. These posters will have links to both the NTSP algorithm and online training modules. Staff

are highly encouraged to complete the training to increase confidence and competence in caring for

those with tracheostomies.

Community Tracheostomy Tube Changes:

Patients with long-term tracheostomies who normally attend UHW or UHL for tracheostomy tube

changes will continue to do so. However, all changes will now be completed in ENT clinic rather than

other locations within the hospital. Furthermore, patients will cuffless tubes will only have their

tracheostomy tube changed every 3 months. Those with cuffed tracheostomy tubes will need to be

individually risk assessed to determine frequency of changes.

Appendix 1:

Tracheostomy Care Bundle:



Appendix 2:



Appendix 3:

Surgical Tracheostomy Checklist for patients with Covid:



Task Complete

or N/A

Bedside nurse at the aware of the planned procedure and that it has been discussed with

the patient/relatives

Critical care technicians are aware so patient/monitoring/drugs/infusions can be

prepared for transfer

NG feed should be stopped at 0600 on the day

Maintenance fluid prescribed if required

Blood bank should have at least 1 valid group & save sample (2 for electronic issue)

Coagulation has been checked and corrected as required

Heparin infusion should be stopped 6 hours pre-procedure and APTTR checked.

Treatment dose LMWH/Oral anticoagulants withheld

Consent for 4 completed by Critical Care senior clinician (for patients unable to consent)

Theatre care plan completed by bedside nurse

Tracheostomy tube of type and size stated above is with the patient ready for transfer

Closed suction device (TT length), adaptor and catheter mount are with the patient ready

for transfer

Notes/Drug chart available for transfer

Equipment to Gather Complete

or N/A

Ambu Bag, Water’s circuit and Face Mask

Bed drip stand

Oxylog ventilator

2 Full CD Oxygen cylinders

Transfer monitor with battery bracket.

Check capnography is visible on monitor

Syringe Drivers if needed

Closed suction adapter and catheter mount (if not already present on ETT)

Tracheostomy Tubes x1 (intended size only)

covid-19 tracheostomy guidance - cardiff icu

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